DISABILITY CLAIM FORM

Transcription

1 DISABILITY CLAIM FORM If you have any questions regarding benefits available, or how to file your claim, or if you would like to appeal any determination, please contact our Customer Care Center at , 8:00 A.M. to 8:00 P.M. Eastern Standard Time or visit our website at The furnishing of this form, or its acceptance by the Company as proof, must not be construed as an admission of any liability on the part of the Company, nor a waiver of any of the conditions of the insurance contract. Mail or Fax Your Claim to: American Heritage Life Insurance Company 1776 American Heritage Life Drive, Jacksonville, FL Fax: If you would like to have claim benefits automatically deposited into your bank account, please complete and send our ACH form (ABJ16661). This form can be found on our website at or POLICYHOLDER / CERTIFICATE HOLDER / CLAIMANT INFORMATION: POLICY / CERTIFICATE NUMBER(s): ; ; POLICYHOLDER / CERTIFICATE HOLDER: First Name MI Last Name Social Security Number*: Date of Birth: Age: Male Female * AB Claims Many Office Depot employees have two policies. Check SSN to find all policy numbers. Mailing Address: Phone #: City: State: Zip: Check here if address is new Employer: Office Depot Occupation: Salary: $ Annually Monthly Job Responsibilities: Were premiums for this policy paid with pre-tax dollars? Yes Apt#: No (If yes, FICA withholding will be deducted from the disability claim payment.) CLAIMANT: (if different) First Name: MI: Last Name: Social Security Number: Date of Birth: Age: Male Female Relation to Insured: Self Spouse Child Other DISABILITY CLAIM DETAILS: Please provide the following details regarding your condition and your ability to work. What is your Diagnosis/Condition? When did you first notice symptoms of your condition? Is your condition work related? Yes No Have you ever had the same or similar condition? Yes No If yes, when: Other conditions affecting your health: Is your condition due to an accidental injury? Yes No Accident Date: Time: AM or PM How did your accidental injury happen? Was a police report filed? Yes No For Motor Vehicle Accidents, you were the: Driver Passenger When was your first physician visit for this condition? Most Recent Visit: Next Visit: Were you hospitalized for your condition? Yes No Admission Date: Discharge Date: What was the first date you were unable to work? Describe why you are/were unable to work: What job duties are/were you unable to perform? Have you returned to work? Yes No Part time/partial duties: / / Full time/full duties: / / Is your condition Pregnancy? Yes No Due Date: Delivery Date: Normal Delivery C-Section Are/were there complications of pregnancy? Yes No If yes, explain: ABJ21500OD 1 of 6 (7/16)

2 CLAIMANT S NAME: POLICY / CERTIFICATE NUMBER(S): Date of Birth: PRIOR DISABILITY COVERAGE **Required** We may require proof of prior disability coverage for review. Did you have prior disability income coverage that was canceled and replaced with this policy? Yes No (Provide details below) Details: Prior Disability Insurance Company Name: Effective Date of Other Coverage: Termination Date of other Coverage (If Applicable): Elimination Period: Benefit Amount: $ (Monthly or Weekly) Maximum Benefit Period: (years/months) OTHER DISABILITY INCOME COVERAGE **Required** Please provide a copy of the approval or denial notification from any other disability income benefits carrier. We may also require proof of the other disability income coverage for review. Do you have other Disability Income Coverage? Yes No (Provide details below.) Have you applied for Disability Income benefits from another source? Yes No (Provide details below) Are you receiving Disability Income Benefits for any other source? Yes No (Provide details below) Type of coverage: Social Security Disability Income Workers Compensation Other Disability Coverage Other: Details: Other Disability Insurance Company Name: Effective Date of Other Coverage: Claim Begin Date: Termination Date of other Coverage (If Applicable): Elimination Period: Benefit Amount: $ (Monthly or Weekly) Maximum Benefit Period: (years / months) DISABILITY POLICY BENEFITS: Please provide the following REQUIRED DOCUMENTATION. *You will be notified if additional information is needed. NEW CLAIM or CONTINUED CLAIM Please complete all sections of the Disability Benefits Claim form. Please have the Attending Physician s Statement completed and signed by your Attending Physician. Please have the Employer s Statement completed and signed by your Employer. (If you are self-employed or unemployed, you will need to complete and sign the statement.) PROVIDERS: Please list all Providers you have seen in the past 2 years including the providers treating you for this Condition. 1. Attending Physician s Name Address Phone # Specialty Dates Consulted Reasons for Visit/Condition 2. Primary Care Physician s Name Address Phone # Specialty Dates Consulted Reasons for Visit/Condition 3. Other Physician/Specialist Name Address Phone # Specialty Dates Consulted Reasons for Visit/Condition 4. Hospital Name Address Phone # Dates Hospitalized Reason for Hospitalization/Condition CERTIFICATION: Please read and sign below I acknowledge the receipt of the Department of Insurance Claim Fraud Statements provided with this claim packet. I have read the notices and I am aware that it is a crime to fill out this form with facts I know are false or to leave out facts I know are relevant and important. I certify that the answers given on this claim form are true, complete, and correctly recorded. Please also remember to sign and date the attached authorization required to process your claim. Signature: Print Name: Date: 2 of 6

3 CLAIMANT S NAME: POLICY / CERTIFICATE NUMBER(S): Date of Birth: ATTENDING PHYSICIAN S STATEMENT: To be completed and signed by the Attending Physician. SECTION #1: DESCRIBE THE CONDITION: ICD 9/10 Code: Primary Diagnosis: ICD 9/10 Code: Secondary Diagnosis: Other Condition(s): When did Symptoms first appear? If applicable, what is the Accident Date? Has the patient ever had the same/similar condition? Yes No When: Is the condition due to injury or sickness arising out of the patient s employment? Yes No Pregnancy or Complication of Pregnancy: Due Date: Delivery Date: Normal Delivery C-Section SECTION #2: TREATMENT REQUIRED: First consultation: Most recent consultation: Next consultation: Released: Is/Was a Surgical or Medical Procedure Required? Yes No Date: Procedure Code: Procedure: Is/was Hospitalization required? Yes No Admission Date: Discharge: Date Hospital: City: State: What is the Current Treatment Plan? SECTION #3: RESTRICTIONS, LIMITATIONS AND ABILITY TO WORK: The patient IS ABLE to work in the following capacity: No Work Sedentary Light Medium Heavy Very Heavy The patient IS UNABLE to perform their job duties: Yes No If Yes: FROM: THROUGH: When is the patient expected to RESUME WORK? Part Time/Partial Duties: Full Time/Full Duties: Please provide the specific RESTRICTIONS: Please provide the specific LIMITATIONS: What CLINICAL or DIAGNOSTIC FINDINGS support these Restrictions and Limitations? SECTION #4: REFERRING PHYSICIAN: Name: Specialty: Address: Phone #: SECTION #5: ATTENDING PHYSICIAN VERIFICATION: Physician Signature: Print Name: Specialty: Phone #: Address: City: State: Zip Code: SECTION #6: CERTIFICATION: I acknowledge the receipt of the Department of Insurance Claim Fraud Statements provided with this claim packet. I have read the notices and I am aware that it is a crime to fill out this form with facts I know are false or to leave out facts I know are relevant and important. I certify that the answers given on this claim form are true, complete, and correctly recorded. Signature: Print Name: Date: Date: 3 of 6

4 CLAIMANT S NAME: POLICY / CERTIFICATE NUMBER(S): Date of Birth: EMPLOYER S STATEMENT: To be completed and signed by your Employer. If you are Self Employed, please complete and sign this form. If you are Unemployed, please provide the last date you worked, your prior employer s name and sign this form. SECTION #1: EMPLOYMENT INFORMATION / JOB DESCRIPTION: Name of Employer/Company: Office Depot Date of Hire: Employee s Job Title/Position: *Please attach a copy of the job description or list major job responsibilities. Major Job Responsibilities: This Job Classification is: Sedentary, Light Work, Medium Work, Heavy Work, Very Heavy Work. Prior to inability to work, he/she worked hours per week. Hourly Pay: $ Annual Salary: $ *If you are self-employed, we may require proof of income. We will notify you if additional documentation is required. SECTION #2: DATES MISSED WORK / RETURNED TO WORK: I hereby certify that did not perform any part of his/her work from through. Has the employee Returned To Work? Yes No Part time/partial duties(date): Full time/full duties(date): Did the employee work part time/partial duty? Yes No Dates: Is part time/partial duty work available? Yes No Reason: When recovered, will he/she resume work? Yes No Reason: SECTION #3: WORKERS COMPENSATION / OTHER DISABILITY COVERAGE / CONTINUED PAY: Is this a Work Related Condition/Injury? Yes No Workers Compensation Begin Date: End Date: Workers Compensation Carrier: Benefit Amount: $ (Monthly/Weekly) Is the employee covered under any Other Disability Policy/Coverage through the Company?* Yes No Other Disability Insurance Carrier: Benefit Amount: $ (Monthly/Weekly) Does this policy Replace any prior Disability Policy/Coverage through the Company?* Yes No Prior Disability Insurance Carrier: Benefit Amount: $ (Monthly/Weekly) Effective Date: Termination Date: Maximum Benefit Period: Elimination Period: *We may require proof of other disability coverage or prior disability coverage for review. Continued Pay: For Group STD & LTD only: Is the insured receiving Continued Pay, Salary Continuation, Sick or Vacation Pay? Yes No Pay Period From Date Through Date Amount Source of Income SECTION #4: Premium: If yes, FICA withholding will be deducted from the disability claim payment. Pre-Tax Premium: Were the premiums for this disability income policy/certificate paid with Pre-Tax Dollars? Yes No Employer Paid: Were premiums for this disability income policy/certificate Employer Paid? Yes No SECTION #5: EMPLOYER VERIFICATION: Check here if Self Employed or Unemployed Signed by: Print Name: Date: Title: Corporate Benefits Company: Office Depot Address: 6600 N Military Trail, Boca Raton, FL Phone #: (888) Option 2 Other Comments: Fax: (561) ; corporate.benefits@officedepot.com SECTION #6: CERTIFICATION: I acknowledge the receipt of the Department of Insurance Claim Fraud Statements provided with this claim packet. I have read the notices and I am aware that it is a crime to fill out this form with facts I know are false or to leave out facts I know are relevant and important. I certify that the answers given on this claim form are true, complete, and correctly recorded. Signature: Print Name: Date: 4 of 6

5 FRAUD WARNINGS BY STATE NOTICE IN ALABAMA: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof. NOTICE IN ALASKA, KENTUCKY, LOUISIANA, MAINE, NEW JERSEY AND NEW MEXICO: Any person who knowingly and with intent to injure, defraud or deceive an insurance company files a claim containing false, incomplete or misleading information may be prosecuted under state law. NOTICE IN ARIZONA: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties. NOTICE IN ARKANSAS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. NOTICE IN CALIFORNIA: For your protection, California law requires the following to appear on this form. Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. NOTICE IN COLORADO: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies. NOTICE IN DELAWARE, IDAHO, INDIANA, MINNESOTA, AND OKLAHOMA: Any person who knowingly and with intent to injure, defraud or deceive an insurance company files a claim containing false, incomplete or misleading information is guilty of a felony. NOTICE IN DISTRICT OF COLUMBIA: FRAUD NOTICE: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits, if false information materially related to a claim was provided by the applicant. NOTICE IN FLORIDA: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. NOTICE IN MARYLAND: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. NOTICE IN NEW HAMPSHIRE: Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA NOTICE IN NEW YORK: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. NOTICE IN OHIO: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. NOTICE IN OREGON: Any person who makes intentional misstatement that is material to the risk may be found guilty of insurance fraud by a court of law. NOTICE IN PENNSYLVANIA: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. 5 of 6

6 NOTICE IN PUERTO RICO: Any person who knowingly and with the intention to defraud includes false information in an application for insurance or file, assist or abet in the filing of a fraudulent claim to obtain payment of a loss or other benefit, or files more than one claim for the same loss or damage, commits a felony and if found guilty shall be punished for each violation with a fine of no less than five thousands dollars ($5,000), not to exceed ten thousands dollars ($10,000); or imprisoned for a fixed term of three (3) years, or both. If aggravating circumstances exist, the fixed jail term may be increased to a maximum of five (5) years; and if mitigating circumstances are present, the jail term may be reduced to a minimum of two (2) years. NOTICE IN TENNESSEE AND WASHINGTON: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. NOTICE IN TEXAS: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. NOTICE IN WEST VIRGINIA AND RHODE ISLAND: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. 6 of 6

7 American Heritage Life Insurance Company 1776 American Heritage Life Drive Jacksonville, Florida CLAIMS ADMINISTRATION DIRECT DEPOSIT AUTHORIZATION FORM TRANSACTION TYPE: New Setup Cancellation Change Financial Institution Change Account Number POLICY/CERTIFICATE HOLDER INFORMATION: Policy/Certificate Holder Name: Home Phone: Policy/Certificate Number(s): Social Security Number: FINANCIAL INSTITUTION: Checking Savings Financial Institution Name: Financial Institution Address: Account Number: *Electronic Routing Transit Number: *Some banks use a separate routing number specifically for electronic ACH deposits. Please verify the routing number with your bank. You may also visit to complete this form electronically. A Voided Check or a Letter From Your Bank Must be Attached In Order to Credit Your Account for Claims Payments Voided Check Requirements: Bank Letter Requirements: Acceptable Accounts and Signatures: - Deposit slips are not accepted; - Letter must be on bank letterhead; - Beneficiary - Insured - Credit and debit cards are not accepted; - Include Account holder s name; - Owner - Payor - Account holder s pre-printed name and address; - Include Account holder s account number: - Power of Attorney - Spouse - Pre-printed account and transit number. - Include Account holder s transit number. Authority is hereby given to American Heritage Life Insurance Company (AHL) to credit the account number shown below for claims payment for all of your AHL policies (unless benefits are assigned). AHL will make any adjustments, including the initiation of any credit or debit entries on the account, for the limited purpose of claims payment due to the account holder or due to AHL. Once the deposit transaction occurs, AHL has five days to withdraw only the amount deposited if an error has occurred. Signing this Authorization will allow AHL to deposit claims payments for all eligible policies. Direct deposit benefit checks will apply to all products underwritten by AHL, excluding Life. Unfortunately, if an insured has assigned benefits to a physician, hospital, another person, etc. the benefit check cannot be direct deposited. Although direct deposit (Electronic Funds Transfer) is my preferred method of payment there may be circumstances which require a paper check to be issued as opposed to a direct deposit. I understand when I do business with AHL and/or its affiliates, parent and subsidiaries, the electronic documents, disclosures and electronic signatures may be utilized by AHL. This authority is to remain in full force and effect until AHL has received written notification revoking the authority. Your policy/certificate holder information and your financial institution information above must be complete and accurate and must be that of the policy/certificate holder on file. To ensure accuracy, a voided check or a bank letter must be attached. Please notify AHL immediately if your financial institution or account information has changed by sending written notification to the address indicated below. Should you have any questions, please contact us at Authorization Signature: Date: Print Name: Deliver the completed and signed authorization form with voided check or bank letter to: Fax to: OR Mail to: Allstate Benefits Attention: Claims ACH Department 1776 American Heritage Life Drive Jacksonville, FL ABJ